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IBRD and IDA: Working for a World Free of Poverty.enShould cash transfers be systematically paid to mothers? https://blogs.worldbank.org/developmenttalk/should-cash-transfers-be-systematically-paid-mothers
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<span>When I was a high school student in Belgium, our history textbook included a reproduction of a painting entitled “The Drunkard” by Eugène Laermans. The painting was included in the section describing the history of the labor movement in the country and its achievements in passing legislation aimed at improving the situation of the working class. In particular, the painting was meant to illustrate why the Belgian law introducing child benefits – monthly transfers to all families raising children until age 18 (or until age 25 as long as they are still students) - stipulates that these benefits are paid to the mother. The law still holds today, even if it allows for exceptions when the mother is not present in the household.</span></p>
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<img alt="" height="295" src="https://blogs.worldbank.org/developmenttalk/files/developmenttalk/laermans-4414dig-l.jpg" title="" width="368" /></p>
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I still remember that painting vividly, many years after graduating from high school. And who knows, it might explain why in my recent research I have been interested in the role played by fathers and mothers in investing in their children’s education, health, and overall welfare.<br />
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In policy circles, both in low and high income countries, it is often assumed that giving transfers to mothers rather than fathers will lead to better outcomes. This assumption is based on more than 19<sup>th</sup> century paintings or anecdotal evidence:&nbsp;several research papers investigating bargaining inside the household suggest that resources under the mother’s control have a stronger positive impact on a child’s health and schooling than when those resources are controlled by the father. For example, <a href="https://ideas.repec.org/a/uwp/jhriss/v25y1990i4p635-664.html" rel="nofollow">Duncan Thomas</a> in 1990 found that in Brazil, unearned income in the hands of a mother has a bigger effect on her family's health than income under the control of a father and that effect is particularly strong for child survival probabilities.<br />
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Presumably because of the influence of this previous line of research, almost all current cash transfer programs give the resources to the mother, so it is not possible to disentangle how much of any impact is due to the recipient’s gender, how much is due to the income effect, and how much is due to the change in relative prices associated with the conditionality.<br />
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However, a <a href="http://r4d.dfid.gov.uk/PDF/Outputs/SystematicReviews/EconomicTtransfer2012Yoong.pdf" rel="nofollow">systematic review</a> by Yoong, Rabinovich and Diepeveen of the role of the recipient’s gender who receives cash transfers concluded that “a substantive body of research that carefully considers issues of selection and attribution is still a crucial missing part of developing gender-mainstreaming in transfer programs” and that given the growing popularity and importance of cash transfers as a poverty alleviation tool across the developing world, it was important to develop the evidence base. &nbsp;<br />
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The randomized control trial that I conducted in rural Burkina Faso together with Richard Akresh and Harounan Kazianga and whose results are reported in <a href="http://documents.worldbank.org/curated/en/2016/06/26529129/evidence-randomized-evaluation-household-welfare-impacts-conditional-unconditional-cash-transfers-given-mothers-or-fathers" rel="nofollow">our recent working paper</a> contributes to this evidence base. The two-year pilot program randomly distributed cash transfers that were either conditional or unconditional and were given to either mothers or fathers. Conditionality was linked to older children enrolling in school and attending regularly and younger children receiving preventive health check-ups. To our knowledge, our study is the only randomized experiment to investigate in the same context both the role of conditionality and the gender of the recipient in a cash transfer program targeting all children, boys and girls, up to age 15 and to study the impact of those different cash transfer modalities on a broad range of education, health, and household welfare outcomes.<br />
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We found that the cash transfers generally improved those outcomes. However, the gender of the transfer’s recipient as well as the conditionality leads to differentiated impacts. For school enrollment and most child health outcomes, conditional cash transfers outperform unconditional cash transfers. We provide further details on the role of conditionality in this<a href="http://www-wds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2013/01/28/000158349_20130128162856/Rendered/PDF/wps6340.pdf" rel="nofollow"> paper</a> and this <a href="http://blogs.worldbank.org/impactevaluations/for-which-children-do-conditions-matter-in-conditional-cash-transfers" rel="nofollow">post</a>.<br />
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Our results on the transfer recipient’s gender suggest that the assumption that it is always better to give transfers to the mother should be questioned or at least nuanced. This is somewhat surprising given the existing empirical evidence suggesting that mothers’ resources have stronger effects on child human capital than fathers’ resources. While giving cash to mothers seems slightly, but not significantly, better for education outcomes, giving cash to fathers leads to significantly better nutritional outcomes during years when the harvest has been poor. Transfers given to fathers also lead to increased livestock ownership, higher agricultural production in cash crops, and relatively more investment in the house’s equipment (electricity and metal roofs).<br />
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These results might be context specific given the strong cultural norm in West Africa prescribing that fathers are responsible for feeding their family, but they still suggest that policy makers should not automatically assume that it is always preferable to have mothers as the transfer’s recipients.</p>
Wed, 06 Jul 2016 14:59:00 -0400Damien de WalqueRisk, Sex and Lotteries. Can lotteries be used as incentives to prevent risky behaviors?https://blogs.worldbank.org/impactevaluations/risk-sex-and-lotteries-can-lotteries-be-used-incentives-prevent-risky-behaviors
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<em>This post is jountly authored by Martina Björkman Nyqvist, Lucia Corno, Damien de Walque and Jakob Svensson.</em><br />
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Conditional cash transfers (CCTs) and other types of financial incentives have been used successfully to promote activities that are beneficial to the participants such as school attendance&nbsp;and health check-ups for children. CCTs pay a certain amount if the condition is verified.<br />
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Lotteries can also be used as an incentive. Instead of being paid a certain amount, the participants who satisfy the condition receive a lottery ticket, a random draw is performed among the tickets, and a predetermined number of winners earn a lottery prize. The value of the lottery prizes would be higher than the typical CCT amount, but the number of recipients of the prizes would be lower.</p>
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The use of lotteries as incentives in public health interventions is not unprecedented. One of the most well-known examples is the 1957 anti-Tuberculosis campaign in Glasgow. <a href="http://www.quackdown.info/article/what-does-science-show-about-incentives-hiv-testing/" rel="nofollow">A blog post by Nathan Geffen</a> reports that intense media coverage and a weekly prize draw resulted in a number of screenings almost three times higher than the initial aim of reaching 250,000 people. He also provides a link to a <a href="http://www.britishpathe.com/video/mass-assault-on-t-b" rel="nofollow">nice vintage video</a> by British Pathé about the Glasgow anti-TB campaign. More recently, the <a href="http://foreignpolicy.com/2013/01/02/the-nudgy-state/" rel="nofollow">HIV screening lottery</a>, developed by <a href="http://www.ideas42.org/" rel="nofollow">ideas42</a>, in the Western Cape Province in South Africa applied the same idea to promote HIV testing and was quite <a href="http://www.scielo.org.za/scielo.php?pid=S0256-95742012000100008&amp;script=sci_arttext" rel="nofollow">controversial</a>, mainly for political reasons. &nbsp;</p>
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<strong><em>The advantages of lottery incentives linked to behavioral economics</em></strong><br />
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Introducing a gamble into an otherwise standard financial incentive program has at least two potential advantages, especially if the program tries to prevent risky behaviors. First, with lotteries the program becomes relatively more attractive to individuals that are willing to take monetary risks. It might be that people who love risk when it comes to money are also more likely to take risks and gamble with their health. They might be more likely to smoke, to drink, to take drugs or engage in risky sex. If this is true, for example in the case of risky sexual behavior, which is responsible for the vast majority of new HIV infections, lottery incentives may then better target those at higher risk of getting infected by HIV.<br />
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Second, there is growing evidence from psychology and behavioral economics that people tend to overestimate small percentages, and therefore prefer a small chance at a large reward to a small reward for sure (<a href="http://www.princeton.edu/~kahneman/docs/Publications/prospect_theory.pdf" rel="nofollow">Kahneman and Tversky, 1979</a>, <a href="http://us.macmillan.com/thinkingfastandslow/danielkahneman" rel="nofollow">Kahneman, 2011</a>, <a href="http://pubs.aeaweb.org/doi/pdfplus/10.1257/jep.27.1.173" rel="nofollow">Barberis, 2013</a>). If so the perceived return from participating in a gamble (lottery) is higher than the return from an incentive program that pays the expected return with certainty, or likewise lotteries may provide stronger incentives for behavioral change compared to a traditional CCT holding the budget constant.<br />
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<strong><em>Lotteries as incentives for HIV prevention</em></strong><br />
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Financial incentives have been tested in the sexual domain to incentivize safe sex and prevent HIV and other sexually transmitted infections (STIs) (<a href="http://wber.oxfordjournals.org/content/26/2/165.short" rel="nofollow">Kohler and Thornton 2012</a>; <a href="http://irps.ucsd.edu/assets/001/503923.pdf" rel="nofollow">Baird et al. 2012</a>; <a href="http://bmjopen.bmj.com/content/2/1/e000747.full.pdf+html" rel="nofollow">de Walque et al. 2012</a>; <a href="http://link.springer.com/article/10.1007%2Fs10198-012-0447-y" rel="nofollow">Galárraga et al. 2013</a>). While some of these studies have shown promising impacts on the prevalence of sexually transmitted infections (STIs) or HIV, none so far demonstrated an impact on HIV incidence, the rate of new infections.<br />
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We used lotteries to design a financial incentive program aimed at HIV prevention in Lesotho:&nbsp; the lottery offered relatively low expected payments but high prizes conditional on negative STI test results.<br />
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As sexually transmitted infections (STIs) can be viewed as markers for risky sexual behaviors, our intervention aimed at modifying the trade-off between the benefit and costs of unprotected sex. If individuals’ decisions on sexual behavior ignore the health externality of risky sexual behavior, such a transfer program can be justified by the negative externalities generated by a higher number of HIV positive individuals within a society.<br />
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The study was a parallel group randomized trial. It had three separate arms – a control arm (N= 1208) and two intervention arms (859 in a low-value lottery arm and 962 in a high-value lottery arm). In the low-value lottery arm individuals were eligible to win lottery prizes worth 500 malotis/South African rands, or approximately $50 every four months. In the high-value lottery arm individuals were eligible to win lottery prizes of twice that amount.<br />
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Individuals in the intervention arms were awarded a lottery ticket if they tested negative for two curable STIs (syphilis and trichomoniasis) in the week before the lottery draw. In expected terms, and conditional on being STI negative, the lottery paid $3.3 every four months in the low-value lottery intervention group, $6.6 in the high-value lottery intervention group. &nbsp;Village level lotteries were organized every four months and 4 lottery winners (one male and one female per lottery arm) per village were drawn.<br />
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Individuals in the intervention arms testing positive for any of the two STIs did not receive a lottery ticket. They could, however, continue as study participants and thus become eligible in subsequent rounds. Individuals in the control arm were not eligible for lottery tickets, but all other study procedures were identical between the control and intervention arms. Anyone testing positive for an STI (regardless of arm) was offered counseling and free STI treatment and individuals testing positive for HIV were referred to public health clinics offering AIDS treatment for appropriate follow-up.<br />
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In a recent <a href="https://ideas.repec.org/p/wbk/wbrwps/7215.html" rel="nofollow">working paper</a>, we report that overall, the lottery incentives had a significant impact in reducing HIV incidence, the rate of new HIV infections among participants who were HIV negative at baseline. &nbsp;Over the two year trial period, the HIV incidence rate was reduced by 2.5 percentage points, or 21.4%, leading to a 3.4 percentage points lower HIV prevalence rate at the end of the trial, in the pooled intervention compared to the control group. To the best of our knowledge, this is the first HIV prevention intervention focusing on sexual behavior changes (as opposed to medical interventions) to have been demonstrated to lead to a significant reduction in HIV incidence, the ultimate objective of any HIV prevention intervention.<br />
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<strong><em>Do risk-lovers like lotteries? </em></strong><br />
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We further explored whether individuals with preferences for risk, based on the perceived value of a risky gamble, are more likely than risk-averse individuals to respond to a prevention scheme with a high but uncertain return conditional on behavioral change. Participants’ preference for risk were measured using a hypothetical risk aversion question in the baseline questionnaire: 62% of the participants report they would prefer a fixed amount of money below the expected value of a lottery instead of taking part in the lottery (risk-averse), while 38% are risk-loving. &nbsp;At baseline, risk-averse and risk-loving individuals had similar demographic and socioeconomic characteristics, but risk-loving participants were less likely to report that they practice safe sex and more likely to be HIV or STI positive.<br />
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Did risk-loving individuals respond differently than risk-averse individuals to the lottery program? Our results suggest they did. HIV incidence was 12.3 percentage points higher for risk-loving compared to risk averse individuals in the control group. HIV incidence among risk-lovers was however 12.2 percentage points lower in the intervention relative the control group: an effect size of 58% in this sub-group. The treatment effect for risk-averse participants was insignificant and the point estimate close to zero, implying that we cannot rule out that the observed decrease in HIV incidence in the pooled intervention compared to the control group was driven solely by the changed behavior of risk-loving individuals.<br />
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<strong><em>The practical advantages of lottery incentives</em></strong><br />
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In addition to targeting the individuals most at risk, the use of lotteries has also practical advantages which are important if we consider scaling-up such programs.&nbsp; First, the administrative costs of a lottery program are likely to be lower compared to a traditional CCT program as only winners need to be paid. Second, we could think of a lottery system whereby only a fraction of the study participants are tested, reducing the cost of testing, an important fraction of the total cost. While the research and ethical protocol for the Lesotho study required that all project participants were offered testing, the incentive for behavioral change will, under certain conditions, remain the same if only lottery winners are tested or if STI screening also is subject to a lottery.<br />
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<a href="http://www.hhs.se/Search/Person/Pages/Person.aspx?PersonID=2557" rel="nofollow">Martina Björkman Nyqvist</a> is Assistant Professor at the Stockholm School of Economics.<br />
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<a href="https://sites.google.com/site/luciacorno/" rel="nofollow">Lucia Corno</a> is Assistant Professor in Economics at the School of Business and Management, Queen Mary University, London.<br />
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<a href="http://www.worldbank.org/en/about/people/damien-de-walque" rel="nofollow">Damien de Walque</a> is Senior Economist in the Development Research Group at the World Bank.<br />
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<a href="http://people.su.se/~jsven/" rel="nofollow">Jakob Svensson</a> is Professor at the Institute for International Economic Studies, Stockholm University.</p>
Wed, 08 Apr 2015 11:39:42 -0400Damien de WalqueCan incentives lead to sustained impacts? The case of rewarding safe sex.https://blogs.worldbank.org/impactevaluations/can-incentives-lead-sustained-impacts-case-rewarding-safe-sex
Economists believe that incentives matter and that they can be used for changing people’s behaviors. Incentives are used for encouraging school attendance and performance or for increasing the coverage and quality of health care delivery. But a recurrent question is what happens once the incentives are discontinued? Are the incentives’ effects going to be sustained even after their payment is stopped because individuals would have been nudged towards a different behavior? Or are those effects going to die down and disappear once incentives are removed? The answer to that question has obvious consequences in terms on long run sustainability and cost effectiveness of incentive schemes.<br />
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Francisco Costa addressed the more general question of the long-term effect of temporary interventions in a previous <a href="http://blogs.worldbank.org/impactevaluations/temporary-interventions-and-new-consumption-habits-guest-post-by-francisco-costa" rel="nofollow">blog post</a>, in which he documented that an eight-month compulsory rationing imposed on Brazilian households’ electricity use in 2001 led to a persistent reduction in electricity use of 14% even ten years later. As he noted, the evidence on the long-term impact of temporary incentives is mixed. On the one hand, <a href="http://www.ingentaconnect.com/content/aea/aejae/2010/00000002/00000004/art00009" rel="nofollow">Giné et al. 2010</a> find in the Philippines that a commitment device for smoking cessation had persistent effect beyond the duration of the intervention and <a href="http://web.stanford.edu/~pdupas/Subsidies&amp;Adoption.pdf" rel="nofollow">Dupas 2013</a> found that a one-time subsidy for antimalarial bed nets in Kenya had a positive impact on willingness to pay for the product a year later. On the other hand, also in Kenya, <a href="http://qje.oxfordjournals.org/content/122/3/1007.short" rel="nofollow">Kremer and Miguel 2007</a> find that take-up of deworming drugs that was initially subsidized was reduced by 80% after the introduction of a small drug cost-recovery program.<br />
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Further, it is often argued that financial incentives might be overemphasizing extrinsic motivation (engaging in a behavior because it is financially rewarded), potentially at the expense of intrinsic motivation (engaging in a behavior because it is valued as such). If this is true, linking financial rewards to some behaviors might destroy the intrinsic motivation and leave us with lower levels of engagement after incentives are stopped.<br />
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The results from a recent experiment rewarding safe sex in Tanzania shed some light on these questions. In order to test innovative approaches to behavioral change to strengthen prevention and stem the HIV/AIDS epidemic, in collaboration with the Ifakara Health Institute in Tanzania and, the University of California at Berkeley, we designed and evaluated a novel intervention using conditional cash transfers (CCTs) for HIV prevention. The intervention tests for risky sexual behavior repeatedly over short time intervals, reinforcing learning about safer sexual behavior with incentives each time.&nbsp;<br />
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The study enrolled 2399 participants in 10 villages in rural south-west Tanzania.&nbsp; The intervention arm received CCTs that depended on negative results of periodic screenings for sexually transmitted infections (STIs) – an objectively measured marker for risky sexual behavior. The intervention arm was further divided into two sub-groups – one receiving a “high value” CCT payment of up to $60 over the course of the study ($20 payments every four months) and the other receiving a lower value payment of up to $30 ($10 payments every four months).<br />
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We have <a href="http://blogs.worldbank.org/africacan/rewarding-safe-sex" rel="nofollow">reported</a> some of the short-term impacts of that CCT intervention incentivizing safe sex on STI prevalence earlier (<a href="http://bmjopen.bmj.com/content/2/1/e000747.full.pdf+html" rel="nofollow">de Walque, Dow, Nathan et al. 2012</a>). At the end of the one year intervention, the results showed a significant reduction in STIs in the group that was eligible for the $20 payments every four months, but no such reduction was found for the group receiving the $10 payments. Further, at the end of the intervention, the impact of the CCTs did not differ between males and females, but the impact was larger among individuals who were STI positive at baseline.<br />
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<strong><em>Can the impacts be sustained once the CCTs are discontinued?</em></strong><br />
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Those are interesting results, but the Tanzanian Minister of Finance would be entitled to ask: do we need to pay people for the entire length of their sexual life in order for them to choose safe sex? This is a fair question. Recognizing that such an intervention would be difficult to sustain over the length of individuals’ sexual lives, we explicitly tested whether they were sustained effects after the end of the intervention. We evaluated its long-term effects using a post-intervention follow-up survey conducted one year after discontinuing the intervention. We left the population on its own for 1 full year, with no testing and no conditional cash transfers. And then after this full year, we came back and tested and interviewed the study participants. We report the results in a <a href="https://ideas.repec.org/p/wbk/wbrwps/7099.html" rel="nofollow">recent working paper.</a><br />
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<strong><em>Learning or Reduced Intrinsic Motivation?</em></strong><br />
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There could be 3 outcomes when testing for sustained effects: i) sustained impacts in reducing STI prevalence, ii) zero long run effects or iii) adverse long run effects.<br />
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For behaviors which individuals may not have tried until encouraged to by the incentives (e.g., use of condoms), it is possible that the incentives will induce learning (and reinforcement) that could result in permanent positive behavior changes even after withdrawal of the incentives.<br />
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The absence of long run effects would rather suggest that incentives need to be continued for sustained effects.<br />
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Alternatively, psychologists have emphasized the potentially pernicious effects of extrinsic monetary incentives in destroying the intrinsic desire to engage in positive behaviors.&nbsp; <a href="http://www.behavior.org/resources/331.pdf" rel="nofollow">Cameron et al. 2001 </a>&nbsp;and <a href="http://www.jstor.org/stable/41337236?seq=1#page_scan_tab_contents" rel="nofollow">Gneezy et al. 2011</a> review the literature on the possible destruction of intrinsic incentives. While Gneezy et al. 2011 conclude that “incentives do matter, but in various and sometimes unexpected ways”, Cameron et al. 2001’s take is that reduced intrinsic motivation might occur for some tasks which are interesting in themselves, for example, drawing pictures among children, but that in general and for tasks which do not present a lot of interest by themselves - condom use in our case of HIV prevention could be an example- incentives do not have pervasive adverse effects.&nbsp;<br />
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<strong><em>Sustained effects, but only for men</em></strong><br />
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The results of the one year post-intervention follow-up indicate that both the high and low values CCTs have had a sustained impact in reducing the STI prevalence by 18 to 20% risk among the study population. &nbsp;They suggest that the CCT interventions might have sustained effect even after the cash payments have been discontinued and that there might a learning effect. They also imply that CCTs do not destroy the intrinsic motivation to adopt safe sexual practices since no increased risk was reported in the intervention groups. Those are important results when considering the potential feasibility at scale and sustainability of our CCT intervention.<br />
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However the disaggregation of the results by gender is interesting. The analysis shows a sustained effect among males but not among females. One possible interpretation of that finding is that, while the CCT intervention contributed to create safer sex habits among men, the cash component of the intervention might be important for women in their efforts to negotiate safe sex.Wed, 14 Jan 2015 16:00:00 -0500Damien de WalqueFrom “Power to the People” to “Information is Power”https://blogs.worldbank.org/impactevaluations/power-people-information-power
<em>This post is co-authored with Martina Björkman Nyqvist and Jakob Svensson</em><br />
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Poor quality plagues public service provision in many developing countries. For example, doctors in Tanzania completed <a href="http://pubs.aeaweb.org/doi/pdfplus/10.1257/jep.22.2.93" rel="nofollow">less than 25%</a> of the essential checklist for patients with malaria, a disease that is endemic in the country. Indian doctors asked an average of one question per patient <a href="http://pubs.aeaweb.org/doi/pdfplus/10.1257/jep.22.2.93" rel="nofollow">(“What’s wrong with you?”</a>). In Uganda, the <a href="http://pubs.aeaweb.org/doi/pdfplus/10.1257/089533006776526058" rel="nofollow">average absence rate</a> among primary school teachers was 27% and 37% among primary health center staff.<br />
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The widespread problem of poor public service delivery in developing countries has in the last decade led to increased attention to evaluate and experiment with different approaches to improve public services provision.<br />
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<strong>Power to the People</strong><br />
One suggested method to fight the poor performance public service delivery is inspired by the Community Driven Development (CDD) approach. It emphasizes participation by the communities served by public services. The approach seeks to enhance beneficiary involvement as a way of strengthening demand-responsiveness and local accountability. These CDD projects have become increasingly popular and the World Bank alone spent about 85 billion USD over the last decade on these types of projects.&nbsp; However, <a href="http://siteresources.worldbank.org/INTRES/Resources/469232-1321568702932/8273725-1352313091329/PRR_Localizing_Development_full.pdf" rel="nofollow">few of the experiences have been rigorously evaluated and the results of those impact evaluations have been mixed.</a><br />
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One rigorous evaluation of such project, however, took place in the primary health care sector in Uganda. The results of this randomized field experiment on community-based monitoring of public primary health care providers have been reported earlier by Martina and Jakob in “<a href="http://qje.oxfordjournals.org/content/124/2/735.short" rel="nofollow">Power to the People</a>”. Localized nongovernmental organizations encouraged communities to be more involved with the state of health service provision by facilitating a set of meetings: (i) a community meeting – a two-day afternoon meeting with community members from the catchment area and from all spectra of society and with on average more than 150 participants per day and per community attending; (ii) a health facility meeting – a half-day event, usually held in the afternoon at the health facility, with all staff attending; and (iii) an interface meeting – a half-day event with representatives from the community and the staff attending. This part of the process focuses on <em>participation.</em><br />
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In order to facilitate a participatory process in which the communities got engaged and focused their discussions on issues where health provider performance and quality of service delivery was low, they also provided the users with information – a report card – about the quality of care provided in their local facility as well as entitlements according to the government standard in comparison to the national and district averages. This element of the intervention emphasizes <em>information. </em><br />
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The final outcome of the process was an action plan jointly agreed upon by the community and the health staff. The action plan outlines the community’s and the providers’ joint agreement on what needs be done to improve health care delivery, how, when, and by whom and how progress will be monitored.<br />
A year into the intervention, treatment communities were more involved in monitoring the providers, and health workers appeared to exert higher effort to serve the community. This resulted in large increases in utilization and improved health outcomes: reduced child mortality and increased child weight.<br />
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<strong>Two questions</strong><br />
The paper, however, raised two questions: 1) are those results sustainable in the longer run, and 2) since the intervention combined a participatory process and the provision of information (which is costly to collect), what would the effect of a more standard participatory intervention be and how important is information in these types of programs?<br />
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In our recent working paper, “<a href="http://www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/2014/08/26/000158349_20140826090814/Rendered/PDF/WPS7015.pdf" rel="nofollow"><em>Information is Power</em></a><em>”</em> we address both questions. First, we did a long-term follow-up of the communities that participated in the initial experiment in Uganda. Between 2006 and 2009 (the long-term follow-up period), the local NGOs re-engaged for a total of four days with the communities based on their initial joint action plan (they did not, however, disseminate any new information, beyond the initial report card nor did they initiate any new processes). Four years after the initial intervention, we find significant longer run impacts of the intervention that combines <em>participation &amp; information</em>. Health care delivery (increased utilization and improved adherence to clinical guidelines) and health outcomes (reduced child mortality and increased weight-for-age and height-for-age for children) improved in the treatment as compared to the control group. For example, the estimated rate-ratio for under-five mortality; i.e., the ratio of the incidence of child deaths in the treatment relative to the control group, implies a 23% reduced risk of under-five deaths in the treatment group.<br />
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<strong>Without information, there is no impact of the pure participatory intervention </strong><br />
Second, we aimed at disentangling how important information is in these types of participatory processes. In parallel with the long-run follow-up of the <em>participation &amp; information</em> intervention, we initiated a second experiment testing a <em>participation (only)</em> intervention. &nbsp;We implemented the participatory component of the intervention described above (and evaluated in <em>Power to the People)</em>, including the three facilitated meetings. But in that participatory experiment we did NOT disseminate any information about the health facility’s performance. No report cards were prepared and shared with the population. Thus, the community now had to build their reform agenda (action plan) on their perceived performance of the local health facility as opposed to the objectively measured performance of the health facility (which was provided to the <em>participation &amp; information intervention group </em>through the information in the report cards).<br />
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The impacts of the interventions with and without information differ markedly. Without information, the process of stimulating participation and engagement (the <em>participation intervention</em>) had little impact on the health workers’ behavior, health outcomes or the quality of health care. It seems that information is an important component in community-based interventions.<br />
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Using data from the implementation phases of the two interventions, we investigate why the provision of information appears to have played such a key role. A core component of both experiments was the agreement of a joint action plan outlining the community’s and the providers’ agreement on what needs be done, and by whom, in order to improve health care delivery.<br />
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While the process of reaching an agreement looks similar on observable measures in the two treatment groups – the same number of community members participated in the community meetings and, on average, the two groups identified the same number of actions to be addressed – the type of issues to be addressed differed significantly.<br />
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In the <em>participation group</em>, the health provider and the community identified issues that primarily required third-party actions; e.g., more financial and in-kind support from upper-level authorities. While in the <em>participation &amp; information</em> <em>group</em>, the participants focused to a much larger extent on problems that could be solved locally, and which either the health workers or the community themselves could address.<br />
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This is well illustrated in Figure 1. The share of local issues is higher in the <em>participation &amp; information</em> <em>group</em> (blue dots) than in the <em>participation group</em> (red triangles). And the share of local issues correlates positively with the changes in the number of outpatients served by the health facility.<br />
<img alt="" height="390" src="https://blogs.worldbank.org/impactevaluations/files/impactevaluations/DamienFigure.jpg" title="" width="520" /><br />
Figure 1: Outpatient care and the share of local issues in the joint action plan<br />
&nbsp;<br />
These results are consistent with the hypothesis that lack of information on health facility performance makes it more difficult to identify and challenge (mis)behavior by the provider. That is, with access to information, users are better able to distinguish between the actions of health workers and factors beyond their control and, as a result, turn their focus to issues that they can manage and work on locally. Finally, when the community takes action in monitoring the providers, the health providers exert higher effort and utilization and health outcomes improve.<br />
&nbsp;<br />
<a href="http://www.hhs.se/Search/Person/Pages/Person.aspx?PersonID=2557" rel="nofollow">Martina Björkman Nyqvist</a> is Assistant Professor at the Stockholm School of Economics.<br />
<a href="http://www.worldbank.org/en/about/people/damien-de-walque" rel="nofollow">Damien de Walque</a> is Senior Economist in the Development Research Group at the World Bank.<br />
<a href="http://people.su.se/~jsven/" rel="nofollow">Jakob Svensson</a> is Professor at the Institute for International Economic Studies, Stockholm University.<br />
&nbsp;Wed, 01 Oct 2014 09:29:00 -0400Damien de WalqueStratified randomization and the FIFA World Cuphttps://blogs.worldbank.org/impactevaluations/stratified-randomization-and-fifa-world-cup
<p>
When I start working on a new impact evaluation, I often begin with a workshop in the country where the study will be conducted. The workshop brings together government officials, both at the central level and from the regions and provinces where the intervention will take place, other stakeholders such as NGOs or other UN organizations, and representatives of the research institution that will implement the survey. Part of the workshop is devoted to teaching or refreshing memories about evaluation techniques. This usually includes a section on randomization which we try to make interactive by doing a randomization game with the participants.</p>
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<p>
Usually, we also explain the principles of blocked or stratified randomization. &nbsp;We need to make sure that the randomization achieves a good balance in several dimensions. We may seek a good balance in terms of geography as well as in terms of some key other characteristics. For example, for evaluating the impact of <a href="http://www.rbfhealth.org/" rel="nofollow">results-based financing in the health sector</a>, we want to achieve a good balance by province or&nbsp; health district, but we also want to obtain a balanced distribution across different type of health facilities: rural vs. urban, hospitals vs. lower level health centers, public vs. private facilities. David and Miriam have a nice <a href="http://blogs.worldbank.org/impactevaluations/tools-of-the-trade-doing-stratified-randomization-with-uneven-numbers-in-some-strata" rel="nofollow">post</a> and a <a href="http://ideas.repec.org/p/wbk/wbrwps/4752.html" rel="nofollow">paper</a> that cover the topic. I <a href="http://blogs.worldbank.org/impactevaluations/public-randomization-ceremonies" rel="nofollow">posted earlier</a> a video showing how we conducted such a stratified randomization during a public ceremony in Cameroon.<br />
<br />
To explain the idea of stratified randomization, I usually compare it with the draw for the football (soccer for American readers) FIFA World Cup. This is the draw that every four year distributes the 32 qualified countries into 8 groups of 4 teams from which the 2 best teams will qualify for the next round.<br />
<br />
In every country where I have organized impact evaluation workshops, the analogy is easy to grasp. The FIFA draw is also a public randomization, and the randomization is "guided" in order to achieve a reasonable balance in terms of continents and in terms of quality of the teams. Everywhere in the world, people understand that it is not fun to have <a href="https://www.youtube.com/watch?v=r9rRVFYF93w" rel="nofollow">Cameroon</a>, Ghana, Côte d'Ivoire and Nigeria or <a href="https://www.youtube.com/watch?v=7YlxvsIEenM" rel="nofollow">Argentina</a>, Ecuador, Chile and Uruguay in the same group. It is also easy for football fans to realize that having Spain, Germany, Argentina and <a href="https://www.youtube.com/watch?v=IBYXU7jUBHM" rel="nofollow">Brazil</a> in the same group, would make it an extremely tough competition and would guarantee that two of the best teams in the world would not play in the second phase of the World Cup.<br />
<br />
Until recently, I thought that my World Cup analogy was bulletproof. But after seeing the results for the 2014 World Cup, I am not sure. Look <a href="https://www.youtube.com/watch?v=7q36eOEz2Hs" rel="nofollow">at the draw for this year.</a> The numbers in brackets are the October 2013 FIFA ranking, which were used to seed the World Cup draw.<br />
<br />
<img alt="" height="167" src="https://blogs.worldbank.org/impactevaluations/files/impactevaluations/Worldcupchart-2.png" width="540" /><br />
<br />
Group B has Spain and the Netherlands, <a href="https://www.youtube.com/watch?v=ufierZ_roW4" rel="nofollow">last World Cup's finalists</a>, in the same group, together with Chile, ranked 12th. <a href="https://www.youtube.com/watch?v=aUYD4joNuvs" rel="nofollow">Italy</a>, <a href="https://www.youtube.com/watch?v=tDpx9GGH79I" rel="nofollow">Uruguay</a> and <a href="https://www.youtube.com/watch?v=QtqiBAg2biw" rel="nofollow">England</a>, all former Word Cup winners - a while ago for the last 2 countries - are together in Group D. And the US, in Group G needs to play against <a href="https://www.youtube.com/watch?v=Ybj5I44nBnE" rel="nofollow">Germany</a> (three times winners), Portugal of <a href="https://www.youtube.com/watch?v=WbTM8VCdRHE" rel="nofollow">Cristiano Ronaldo</a> and Ghana who <a href="https://www.youtube.com/watch?v=3MpMBEmBBsQ" rel="nofollow">beat</a> them in the second phase 4 years ago. Meanwhile, <a href="https://www.youtube.com/watch?v=C-I25588h9o" rel="nofollow">France</a> in Group E seems to be in a relatively easier group with Switzerland, Ecuador and Honduras.<br />
<br />
Is this the result of a bad draw that led to a relatively unbalanced distribution in terms of teams’ strength? Julien Guyon, a French mathematician thinks otherwise. In <a href="http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2424376" rel="nofollow">an academic paper</a> and two blog posts, one in <a href="http://www.nytimes.com/2014/06/05/upshot/the-world-cup-draw-is-unfair-heres-a-better-way.html" rel="nofollow">English</a> and one in <a href="http://www.lemonde.fr/coupe-du-monde/article/2014/06/04/il-faut-repenser-le-tirage-au-sort-de-la-coupe-du-monde_4431571_1616627.html" rel="nofollow">French</a>, he explains that the current rules put too much emphasis on the geographic constraints and as a consequence neglect the team quality dimension.<br />
<br />
Guyon then goes on and proposes a new method for the draw. I will not describe his method in detail as his paper and blog posts do so eloquently. His method is different from FIFA’s in this way: all the teams are seeded, according to their world ranking, 1 through 32. The teams are then assigned groups in a manner similar to other sport tournaments, like the NBA play-offs, with an attempt to group higher-rated teams with lower-rated ones. He then maintains FIFA’s geographical constraints by randomly selecting continental groupings in advance.<br />
<br />
In his paper, he reports the result from one draw using his method.<br />
<br />
<img alt="" height="168" src="https://blogs.worldbank.org/impactevaluations/files/impactevaluations/worldcupchart1.jpg" width="540" /><br />
<br />
He then demonstrates, using the sums, range and standard deviation of rankings, that this draw is more balanced than the one made by the FIFA in December 2013. Most football fans will have seen this even without resorting to statistics. A <a href="http://www.nytimes.com/interactive/2014/06/03/upshot/world-cup-draw-simulation.html?_r=0" rel="nofollow">post</a> on the Upshot blog also allows the reader to simulate their own draws using the FIFA and the Guyon methods. Based on 10,000 simulations, the post also compares for each of the 32 countries participating in the World Cup the likelihood of having an easy or a strong group using either the Guyon or the FIFA methods. The variances are much lower using the Guyon method, so most countries are less likely to be drawn in a very easy group or a very hard one.&nbsp;<br />
<br />
Finally, I have peppered this post with links to videos of memorable events in World Cup history. Enjoy! And if in the coming weeks you get caught by your boss or colleagues watching a game on your computer, you can always claim that you are digging into the supplementary material offered by a blog post on stratified randomization.<br />
<br />
&nbsp;</p>
Wed, 11 Jun 2014 09:37:00 -0400Damien de WalqueRisking Your Healthhttps://blogs.worldbank.org/health/risking-your-health
<p>
<img alt="" src="https://blogs.worldbank.org/health/files/health/ryh-blog_0.jpg" style="height:332px; width:500px" /><br />
All over the world, people engage in behaviors that are risky for their health. They smoke, use illicit drugs, drink too much alcohol, eat unhealthy food or adopt sedentary lifestyles, and have risky sexual encounters. As a consequence, they endanger their health, reduce their own life expectancy, and often impose harmful consequences on others.</p>
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<p>
In a new World Bank book, <a href="http://documents.worldbank.org/curated/en/2013/10/18486155/" rel="nofollow">Risking your Health: Causes, Consequence and Interventions to Prevent Risky Behaviors</a>, we regroup these five risky behaviors – drugs, smoking, alcohol, unhealthy food and risky sex – and investigate them under a common lens, describing global trends in prevalence and discussing determinants and consequences. The book reviews empirical evidence to examine what works and what doesn’t to prevent those behaviors. Legislation and taxation, for example, can be effective, especially when combined with strong enforcement mechanisms. Cash transfers also have proven to be promising in some settings. &nbsp;Behavior change campaigns, such as school-based sex education and calorie-labeling laws, are often less effective on their own.<br />
<br />
Despite recent progress in prevention and treatment, the HIV/AIDS epidemic –one of the most devastating consequences of risky sex— remains a heavy burden in sub-Saharan Africa, especially in its southern cone where between 11% and 26% of all adults are HIV-positive. Drug and alcohol abuse have been relatively stable over the past decade, but smoking and obesity linked to unhealthy diets and physical inactivity are on the rise in many developing countries and have the potential to substantially increase mortality and morbidity.<br />
<br />
Close to 20% of the world’s adult population smokes cigarettes; globally, smoking causes more than 15% of premature deaths among men and 7% among women. While smoking prevalence is decreasing in the developed world, it is on the rise in many developing countries. Obesity is also increasing in the developing world, especially in the Middle East, Latin America and the Caribbean and the Pacific Islands where many countries are experiencing obesity rates above 20% for males and more than 40% for females.<br />
<br />
By engaging these risky behaviors, individuals are trading their long-term well-being for immediate satisfaction. Indeed, one trait that is shared by these behaviors is the disconnect between the pleasure or satisfaction they provide and the consequences they entail. If smoking killed quickly, few people would choose to light a cigarette. But there is usually a long lag between the enjoyment of the “guilty pleasure” and the negative health consequences. Moreover, these health behaviors are considered to be “risky” because the outcomes are not always certain. Not all smokers die from lung cancer, not all heavy drinkers suffer from liver cirrhosis, and not everyone who has multiple sexual partners without using condoms becomes HIV-positive.<br />
<br />
In contrast with other ailments, the illnesses caused by these risky behaviors are, ultimately, the result of decisions made by individuals, even if those decisions have complex motivations. Individuals decide to light a cigarette, consume drugs, order alcoholic drinks, eat junk food, or have unprotected sex.&nbsp;<br />
<br />
But, if they are the results of individual decisions, risky behaviors rarely occur in isolation. Peer pressure, parental influences, networks, and social norms often play important roles in the choices to initiate, continue, or quit those behaviors. Even if they might be the first to suffer, the consequences of risky behaviors are rarely limited to those engaging in them. In certain cases, the link is direct: drug consumption, smoking, alcohol use, poor diet, and HIV among mothers have detrimental impacts on their fetuses; second-hand smoking is a serious health hazard to others; and unprotected sex and needle-sharing lead to the spread of HIV and other sexually transmitted infections. In other cases, the link is less direct but not necessarily less real: the long-term health consequences of many of these behaviors are costly and could stretch households’ finances and exacerbate poverty. Finally, these risky behaviors have consequences for society as a whole, since they often trigger significant public health expenditures and lead to declines in aggregate productivity through premature mortality and morbidity.<br />
<br />
The costly impacts that accrue to individuals in developing countries, in addition to the presence of large negative spill-overs, suggest that public intervention to prevent or reduce engagement in these behaviors can improve overall welfare. How can the individual decisions to consume drugs, tobacco or alcohol, eat junk food or engage in risky sex be influenced by public interventions?&nbsp;<br />
<br />
Providing information about the dangers associated with the risky behaviors is important, but is rarely enough. People have known for years that tobacco kills, but many continue to smoke. They know how HIV is transmitted and how to prevent infections, but many prefer not to use condoms, even though they are widely available.<br />
<br />
Economic mechanisms such as taxes, for example on alcohol and tobacco products, by raising the price of the “guilty” pleasure, have the advantage of directly affecting the trade-off between immediate satisfaction and long-term well-being. Tobacco or alcohol taxes have been very effective at decreasing consumption, as illustrated by the figure below for cigarette taxes in the US. Such taxes are a “win-win” since they decrease the prevalence of risky behaviors while also increasing government revenue. They are also used by many developing countries and their introduction and expansion should be further encouraged.<br />
<br />
<strong>FIGURE. Cigarette sales and average price per pack* --- United States, 1970--2008</strong><br />
<img alt="" src="https://blogs.worldbank.org/health/files/health/table.gif" style="height:194px; width:540px" /><br />
<br />
SOURCE: Chaloupka FJ. The economics of tobacco taxation. Chicago, IL: ImpacTEEN, University of Illinois at Chicago; 2009. Available at <a href="http://www.impacteen.org/generalarea_PDFs/Chaloupka_TobaccoTaxes_AK_041609.pdf" rel="nofollow">http://www.impacteen.org/generalarea_PDFs/Chaloupka_TobaccoTaxes_AK_041609.pdf</a>.<br />
* Adjusted to February 2009 dollars.<br />
<br />
Changing private, self-destructive behaviors is difficult, but we are gradually developing a better understanding of them and better policy tools to deal with the growing threat they represent.<br />
<br />
<em>Follow the World Bank health team on Twitter:&nbsp;<a href="https://twitter.com/worldbankhealth" rel="nofollow">@worldbankhealth</a>&nbsp;.</em><br />
<br />
<strong>RELATED</strong><br />
<a href="http://www.worldbank.org/en/news/press-release/2013/11/20/risky-behaviors-growing-threats-global-health" rel="nofollow">Press Release:&nbsp;Risky Behaviors Constitute Growing Threats to Global Health</a><br />
<a href="http://documents.worldbank.org/curated/en/2013/10/18486155/" rel="nofollow">Report:&nbsp;Risking Your Health : Causes, Consequences, and Interventions to Prevent Risky Behaviors</a><br />
&nbsp;</p>
Wed, 20 Nov 2013 10:22:00 -0500Damien de WalquePublic randomization ceremonieshttps://blogs.worldbank.org/impactevaluations/public-randomization-ceremonies
<p>
<em>With Jake Robyn* and Gaston Sorgho**</em><br />
<br />
Randomization might- at first – sound like a scary word for health policy makers and professionals. They read medical journals and know from their training that randomized trials are scientifically rigorous designs to evaluate the impact of a program. But their first inclination might be to prefer to have the randomized trial in somebody else’s backyard. Randomization seems politically difficult. How to explain it to the people who will have to wait for the new intervention? Will it not create a backlash with the people who are randomly assigned to the control group? How will the population be convinced that the random allocation was fair and that there were no back room deals?<br />
<br />
Our experience in many countries is that public randomization ceremonies are an excellent platform to build support for randomization and for the entire impact evaluation process. In Cameroon, we organized public randomization ceremonies in three Regions to assign health facilities to four study groups in an impact evaluation of performance-based financing (PBF) in the health sector. Held in the regional capitals and combined with the official launching of the project in each Region, we invited representatives of each facility, district health management teams, and local government, who all took part themselves in the randomization. Each of the randomization ceremonies received close oversight from the central and regional levels of the Ministry of Public Health. This made the randomization process completely fair and transparent to all health facilities participating in the study.</p>
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<p>
We made a video of those ceremonies in Cameroon illustrating the process and the reception by health facility representatives. The film includes images from all three regions but primarily focuses on the ceremony held in the Eastern Region of Cameroon in July 2012. The video provides context for the evaluation – for those readers interested in just seeing the randomization in action, skip ahead and watch from minute 6:32 to 13:15, and from minute 2:34 to 3:36 for the preparation of the randomization blocks.</p>
<div class="asset-wrapper asset aid-1 asset-video"> <strong >
Impact Evaluation of Results Based Financing </strong>
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<p>
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<br />
The video is pretty much self-explanatory, but here is some additional background on the PBF project in Cameroon and its impact evaluation which will provide some context. With the objective of improving maternal and child health outcomes, Cameroon has recently started to implement performance-based financing (PBF) in the health sector.&nbsp;<br />
<br />
<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3040374/" rel="nofollow">Performance-based financing</a> is as a mechanism by which health providers are, at least partially, funded on the basis on their performance, usually measured both in terms of quantity and quality of services delivered. Performance-based financing can be contrasted with the line-item approach, which finances a health facility through the provision of inputs (e.g. drugs, personnel). The Ministry of Public Health, in collaboration with the World Bank, has launched a pilot implementing PBF in public and private facilities across 26 districts in the Littoral, North-West, South-West and East regions of Cameroon covering a total population of approximately 2.8 million. The impact evaluation is conducted in 14 of these districts.</p>
<p>
PBF does not only introduce a new incentive mechanism for health facilities and health care providers. It also comes with reinforced supervision and increased managerial autonomy. In addition, PBF will also increase the amount of resources available for the health facility. So, the full PBF package implies performance incentives, an increased budget and stronger supervision and larger financial autonomy. The impact evaluation is designed to isolate the effect of these different components, and has the following four groups:</p>
<ol>
<li>
&nbsp;T1: the treatment group that gets the full PBF program</li>
<li>
C1: a control group which experiences the same level of supervision and managerial autonomy and an equivalent amount of per capita financial resources as in T1, but those resources are not linked to performance.</li>
<li>
C2: no additional resources compared to the status quo, but enhanced supervision and monitoring will be performed</li>
<li>
&nbsp;C3: Status quo, with no interventions.</li>
</ol>
<p>
The comparison between T1 and C1 can isolate the effect of performance-based incentives. The comparison between C1 and C2 allows isolating the effect of increased financial resources and managerial autonomy. The comparison between C2 and C3 allows focusing on the effect of enhanced supervision and monitoring. Comparing the results in T1 with those in C3 will show the impact of the full PBF package.<br />
<br />
Because of sample size requirements (we needed about 50 units in each of the four groups), the random allocation between the 4 groups had to be done at the level of the health facilities. &nbsp;To make sure that all three regions and all type of facilities (public vs. private) were equally represented in each four groups in each region, we blocked the randomization at the regional level and within regions by health facility characteristics. In one region, not shown in the video, we further blocked by rural vs. urban. We took care of the “blocking” by regions by organizing three different public randomization ceremonies, as described above. The blocking by type of facility was done by conducting the randomization process within each health facility block in turn. As shown in the video (minute 2:34 to 3:36), we first put the names of the private and the public health facilities in two different bowls. Next, we first proceeded with the randomization for the private health facilities (starting at minute 8:27), and finally randomized the public facilities into the four groups (starting at 9:40).</p>
<br />
*Jake Robyn is a Health Specialist in the Africa Region of the World Bank.<br />
<br />
**Gaston Sorgho is a Lead Public Health Specialist in the Africa Region of the World Bank.Tue, 18 Jun 2013 08:55:00 -0400Damien de WalqueTransferts monétaires conditionnels au Burkina Faso: Pour quels enfants les conditions sont-elle importantes?https://blogs.worldbank.org/africacan/transferts-mon-taires-conditionnels-au-burkina-faso-pour-quels-enfants-les-conditions-sont-elle-impo
<P><SPAN style="FONT-SIZE: smaller"><EM><STRONG><IMG alt="" align=left src="http://blogs.worldbank.org/africacan/files/africacan/programa_de_transfers.jpg" width=240 height=148>Auteurs: Richard Akresh, Damien de Walque et Harounan Kazianga</STRONG></EM></SPAN></P>
<P>Dans une <A href="http://www-wds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2013/01/28/000158349_20130128162856/Rendered/PDF/wps6340.pdf">récente étude</A>, nous présentons les impacts sur l’éducation d’un projet-pilote de transferts monétaires au Burkina Faso<SUP>1</SUP>, dans la Province du Nahouri. Ce projet-pilote est accompagné d’une évaluation d’impact expérimentale randomisée pour mesurer et comparer, dans le même contexte en zone rurale au Burkina Faso, l’efficacité de transferts monétaires conditionnels et non-conditionnels qui ciblent les ménages pauvres. Les programmes de transferts monétaires conditionnels (TMC), comme les transferts monétaires non-conditionnels (TMNC), transfèrent des ressources monétaires aux ménages pauvres à intervalles réguliers. Mais la différence principale c’est que les TMC imposent des conditions aux ménages, telles que l’inscription et la fréquentation scolaire pour les enfants d’âge scolaire.</P>
<P>Avec les TMC, si les conditions ne sont pas respectées pour une période donnée, les transferts ne sont pas payés pour cette période. Au contraire, avec les TMNC, il n’y pas de conditions à respecter.<!--break--></P>
<P>La question-clef de l’étude est donc celle du rôle joué par les conditions dans les programmes de TMC : <STRONG>ces conditions influencent-elles les comportements qu’elles cherchent à améliorer?</STRONG> Notre étude se concentre sur les différents impacts que les deux types de transferts monétaires ont sur l’éducation des enfants de 7 à 15 ans.</P>
<P><STRONG>Les TMC ont un impact plus fort que les TMNC pour les enfants « marginaux »</STRONG></P>
<P>Nous développons et testons de manière empirique l’hypothèse que les TMC sont plus efficaces que les TMNC pour améliorer l’inscription scolaire des enfants “marginaux”, ceux qui sont moins susceptibles d’y aller, tels que les filles, les enfants plus jeunes et les enfants moins doués. Notre point de départ est l’observation que dans cet environnement souvent les parents choisissent de manière stratégique d’investir davantage dans l’éducation de certains de leurs enfants. Dans ce <A href="http://siteresources.worldbank.org/INTPUBSERV/Resources/EDCCAkreshBagbydeWalqueKazianga.pdf">papier </A>et cet autre <A href="http://www-wds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2012/02/09/000158349_20120209150137/Rendered/PDF/WPS5965.pdf">papier</A>, ainsi que dans ce post de <A href="http://blogs.worldbank.org/africacan/rivalit-fraternelle-au-burkina-faso">blog en Français</A>, utilisant notre enquête de base, nous avons documenté que les parents décident de manière stratégique, lesquels de leurs enfants ils vont inscrire à l’école en se basant sur les capacités cognitives de ceux-ci. Notre échantillon de recherche comprend tous les enfants (garçons et filles de 7 à 15 ans), et donc nous pouvons comparer de manière explicite les impacts différents des conditions sur les enfants « marginaux » comparés aux autres.</P>
<P>Nos résultats indiquent que <STRONG>les TMC sont plus efficaces que les TMNC pour augmenter l’inscription scolaire des enfants “marginaux”, les filles, les enfants plus jeunes (7 à 8 ans), et les enfants moins doués.</STRONG>&nbsp; Avec des transferts annuels de 8000 Francs CFA ($17,6) pour les enfants de 7 à 10 ans et de 16000 Francs CFA ($35,2) pour les enfants de 11 à 15 ans, nous trouvons les résultats suivants:</P>
<P>- Les TMC entraînent une augmentation statistiquement significative de l’inscription scolaire de&nbsp; 20,3 pourcent pour les filles, de 37,3 pourcent pour les jeunes enfants, et de 36,2 pourcent pour les enfants moins doués.</P>
<P>- Pour les mêmes catégories d’enfants, les TMNC n’ont, soit pas d’impact significatif sur l’inscription scolaire, soit un impact qui est significativement moindre que l’impact des TMC.</P>
<P>Cependant, nous trouvons que <STRONG>les TMC et les TMNC ont des effets similaires pour augmenter le taux d’inscription des enfants que les parents privilégient généralement pour l’inscription, tels que les garçons, les enfants plus âgés (9 à 13 ans) et les enfants plus doués.</STRONG></P>
<P>- Les TMC et les TMNC augmentent respectivement l’inscription de 21,8 et 22,2 pourcent parmi les garçons, 17,4 et 14 pourcent parmi les enfants plus âgés, et 27 et 28,5 pourcent parmi les enfants plus doués.</P>
<P>Nous illustrons ces résultats par les figures 1 et 2 dans lesquelles nous comparons l’augmentation en pourcent de l’inscription scolaire dans les villages TMC et TMNC par genre (figure 1) et par groupe d’âge et niveau de capacité (figure 2).</P>
<P><IMG alt="" src="http://blogs.worldbank.org/africacan/files/africacan/figure1adw.jpg" width=472 height=342></P>
<P><IMG alt="" src="http://blogs.worldbank.org/africacan/files/africacan/figure1dw.jpg" width=473 height=345></P>
<P>Les transferts monétaires que nous avons étudiés au Burkina Faso couvrent garçons et filles dans un large groupe d’âge et ont un impact sur les deux aspects de l’inscription scolaire: amener les enfants non-inscrits à fréquenter l’école et diminuer le décrochage scolaire. Cela nous permet d’investiguer pourquoi les conditions liées aux TMC fonctionnent et pour quels enfants elles sont les plus efficaces. Dans des environnements aux ressources limitées, tant les TMC que les TMNC augmentent le budget des ménages et permettent à ceux-ci d’inscrire davantage d’enfants qu’ils ont tendance à traditionnellement favoriser en matière d’investissement éducatif.&nbsp;&nbsp; Mais les conditions liées aux TMC jouent un rôle critique pour améliorer la situation scolaire des enfants pour lesquels les parents ont moins tendance à investir.&nbsp;</P>
<P><STRONG>Implications pour la politique d’éducation</STRONG></P>
<P>Les implications de ces résultats sont claires: le choix entre TMC et TMNC dépend des objectifs de la politique d’éducation :<BR>- Si l’objectif est d’augmenter le taux d’inscription de manière générale, les TMNC ont sans doute des effets comparables à ceux des TMC.</P>
<P>- Mais si l’objectif comprend aussi un souci particulier d’améliorer la participation scolaire des enfants qui sont généralement moins bien intégrés au système scolaire, alors les TMC auront sans doute davantage d’impact et leur coût-efficacité sera plus grande. Cette conclusion prend toute sa valeur dans le contexte de l’Objectif du Millénaire 3 qui veille à réduire les inégalités de genre en matière d’éducation.&nbsp;</P>
<P><STRONG>Mettre en œuvre des programmes de TMC dans un contexte africain</STRONG></P>
<P>Une des contributions de cette étude est aussi de montrer que des programmes de transferts monétaires conditionnels peuvent être mis sur pied en Afrique sub-saharienne. En effet, les programmes de TMC doivent s’appuyer sur un certain degré de capacité administrative : capacité de cibler les ménages éligibles, de planifier des réunions les informant de leurs droits et obligations, de vérifier périodiquement que les conditions requises pour les transferts sont satisfaites par les ménages et de transférer les fonds aux bénéficiaires. Il y a dès lors débat sur la question de savoir si ce type de programmes, qui ont obtenu des succès en Amérique Latine, peuvent également être mis en œuvre effectivement par les administrations centrales ou locales en Afrique.&nbsp;</P>
<P>Le programme de transferts monétaires que nous avons étudié s’appuyait sur les structures gouvernementales existantes et a été mis en œuvre dans un environnement sans registre complet de la population et où une très faible partie de la population a accès aux services bancaires. Comme suggéré dans la photo ci-dessus, la logistique des transferts monétaires ne reposait pas sur des technologies avancées. Le gouvernement&nbsp; distribuait l’argent lors d’une réunion qui se tenait tous les trimestres au centre de chaque village. Dans les villages TMC, l’inscription et la fréquentation scolaire étaient vérifiées par la signature du maître d’école dans un carnet prévu par le programme, avec un audit aléatoire dans les registres scolaires pour une fraction des enfants. Même si cette étude est un projet de deux ans limité à une province et que le passage à l’échelle doit encore être étudié, elle indique toutefois que les TMC peuvent être mis en œuvre et avoir un impact dans le contexte africain.</P>
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<P><SUP>1</SUP> Un projet mis en œuvre par Secrétariat Permanent du Comité National pour la Lutte contre Sida et les Infections Sexuellement Transmissibles du Burkina Faso.<BR>&nbsp;</P>
<P><SPAN style="FONT-SIZE: smaller"><EM>- </EM></SPAN><A href="http://faculty.las.illinois.edu/akresh/"><SPAN style="FONT-SIZE: smaller"><EM>Richard Akresh</EM></SPAN></A><SPAN style="FONT-SIZE: smaller"><EM> est Assistant Professor en Economie à l’Université d’Illinois à Urbana-Champaign, Etats-Unis.<BR><BR>- </EM></SPAN><A href="http://go.worldbank.org/0TJZWJJCM0"><SPAN style="FONT-SIZE: smaller"><EM>Damien de Walque</EM></SPAN></A><SPAN style="FONT-SIZE: smaller"><EM> est Economiste Principal au Groupe de Recherche en Développement de la Banque Mondiale.&nbsp;<BR><BR>- </EM></SPAN><A href="http://www.hkazianga.org/"><SPAN style="FONT-SIZE: smaller"><EM>Harounan Kazianga</EM></SPAN></A><SPAN style="FONT-SIZE: smaller"><EM> est Assistant Professor en Economie au Département d’Economie de la William Spears School of Business, Oklahoma State University, Etats-Unis</EM></SPAN><BR>&nbsp;</P>Mon, 11 Feb 2013 12:34:22 -0500Damien de WalqueFor Which Children Do Conditions Matter in Conditional Cash Transfers?https://blogs.worldbank.org/impactevaluations/for-which-children-do-conditions-matter-in-conditional-cash-transfers
<p><SPAN style="COLOR: red; FONT-SIZE: 11pt">Co-authored with Richard Akresh and Harounan Kazianga</SPAN></p>
<p><SPAN style="FONT-SIZE: 11pt">Social safety nets are actively promoted in developing countries both as responses to financial crises and as mechanisms to alleviate poverty. Conditional cash transfers, which are now common in Latin America but remain rare in other regions, are also seen a way to reduce future poverty by investing in the human capital of the next generation (<A href="http://go.worldbank.org/H9PAWAIX70"><FONT color=#0000ff>Fiszbein and Schady, 2009</FONT></A>). While both conditional cash transfers (CCTs) and unconditional cash transfers (UCTs) provide poor households with resources, UCT programs do not impose conditionality constraints. <B>An important question is whether and how conditions influence the outcomes they seek to improve</B>.</SPAN></p>
<p>&nbsp;</p>
<p><SPAN style="FONT-SIZE: 11pt">In a recent <A href="http://www-wds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2013/01/28/000158349_20130128162856/Rendered/PDF/wps6340.pdf"><FONT color=#0000ff>working paper</FONT></A>, we present evidence of the education impacts from a cash transfer pilot program in rural Burkina Faso, the Nahouri Cash Transfers Pilot Project (NCTPP). The NCTPP incorporated a random experimental design to evaluate the relative effectiveness of conditional and unconditional cash transfers targeting poor households in the same setting in rural Burkina Faso. We focus on the differential impact of those two types of cash transfers on the educational outcomes of children between the ages of 7 to 15.</SPAN></p>
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<p><B><SPAN style="FONT-SIZE: 11pt">CCTs work better than UCTs for “marginal” children</SPAN></B></p>
<p><B>&nbsp;</B></p>
<p><SPAN style="FONT-SIZE: 11pt">We develop and empirically test the hypothesis that CCTs will be more effective than UCTs in improving the enrollment of “marginal children”, those who are less likely to go to school, such as girls, younger children, and children with lower cognitive ability<B>.</B> We observe that parents in this setting often decide strategically to invest more in the education of some of their children (see our previous <A href="http://www-wds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2012/02/09/000158349_20120209150137/Rendered/PDF/WPS5965.pdf"><FONT color=#0000ff>research</FONT></A> using our baseline survey to explore this issue). Because our sample population includes all children (boys and girls ages 7-15), we can explicitly measure the differential impacts of conditionality on “marginal” children compared to other children.</SPAN></p>
<p>&nbsp;</p>
<p><SPAN style="FONT-SIZE: 11pt">Our results indicate that <B>CCTs are more effective than UCTs in improving the enrollment of “marginal” children, <SPAN style="COLOR: #222222">those who are are less likely to go to school,</SPAN> including girls, younger children, and lower ability children</B>: With yearly transfer amounts of $17.6 for children ages 7-10 and $35.2 for children ages 11-15, we find that:</SPAN></p>
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<p><SPAN style="FONT-SIZE: 11pt">·<SPAN style="FONT: 7pt 'Times New Roman'">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN></SPAN><SPAN style="FONT-SIZE: 11pt">CCTs led to statistically significant increases in enrollment of 20.3 percent for girls, 37.3 percent for younger children, and 36.2 percent for low ability children relative to mean enrollment in those sub-groups. </SPAN></p>
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<p><SPAN style="FONT-SIZE: 11pt">·<SPAN style="FONT: 7pt 'Times New Roman'">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN></SPAN><SPAN style="FONT-SIZE: 11pt">For these same categories of marginal children, UCTs either had no statistically significant impact or showed an impact that was significantly smaller than the CCT effect. </SPAN></p>
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<p><SPAN style="FONT-SIZE: 11pt">However, we find that <B>UCTs and CCTs have similar impacts in increasing the enrollment of children who are traditionally prioritized by parents for school participation, including boys, older children, and higher ability children</B>. </SPAN></p>
<p><SPAN style="FONT-SIZE: 11pt">·<SPAN style="FONT: 7pt 'Times New Roman'">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN></SPAN><SPAN style="FONT-SIZE: 11pt">We find enrollment increases due to CCTs and UCTs respectively of 21.8 and 22.2 percent for boys, 17.4 and 14 percent for older children, and 27.0 and 28.5 percent for higher ability children. </SPAN></p>
<p>&nbsp;</p>
<p><SPAN style="FONT-SIZE: 11pt">We graphically illustrate these results in Figures 1 and 2 in which we compare the percentage increases in enrollment in the UCT and CCT villages by gender (Figure 1) and by age group and ability level (Figure 2).</SPAN></p>
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<p><SPAN style="FONT-SIZE: 11pt"><IMG alt="" src="http://blogs.worldbank.org/impactevaluations/files/impactevaluations/figure1damien.jpg" width=500 height=375></SPAN></p>
<p><SPAN style="FONT-SIZE: 11pt"><IMG alt="" src="http://blogs.worldbank.org/impactevaluations/files/impactevaluations/figure2damien.jpg" width=500 height=375></SPAN></p>
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<p><B><SPAN style="COLOR: black; FONT-SIZE: 11pt">Reconciling our findings with Baird, McIntosh, and Özler’s 2011 results in Malawi</SPAN></B></p>
<p><B>&nbsp;</B></p>
<p><SPAN style="FONT-SIZE: 11pt">Our results shed new light on the role of conditionality in cash transfer programs. While there is credible evidence that both types of transfer schemes can substantially improve child education, only one published study explicitly compares conditional and unconditional cash transfers in the same context (<A href="http://qje.oxfordjournals.org/content/early/2011/10/12/qje.qjr032.full.pdf+html"><FONT color=#0000ff>Baird, McIntosh, and Özler, 2011</FONT></A>).<A title="" href="http://blogs.worldbank.org/impactevaluations/node/add/blog#_ftn1" name=_ftnref1><SPAN><SPAN><SPAN><SPAN style="FONT-SIZE: 11pt"><FONT color=#0000ff>[1]</FONT></SPAN></SPAN></SPAN></SPAN></A> They examine the impact of conditionality on the drop-out rates of adolescent girls enrolled at baseline in Malawi and find that CCTs are more effective than UCTs for these girls. Our results are different from theirs. We find that CCTs are more effective than UCTs for marginal children, while UCTs are equally effective as CCTs for non-marginal children. However, we might be able to reconcile the results from Malawi and Burkina Faso. If we consider that in Malawi adolescent girls in secondary school (the focus of the Malawi experiment) may be considered as “marginal” children from an education point of view, then our marginal child hypothesis would predict that for them CCTs would be more effective than UCTs. </SPAN></p>
<p>&nbsp;</p>
<p><SPAN style="FONT-SIZE: 11pt">Our cash transfer intervention in Burkina Faso focused on a broad range of child age and gender and on both margins of school enrollment (bringing non-enrolled children into school and reducing drop-outs) and therefore allows us to investigate how conditionality works and specifically for which types of children it works best for. In resource-poor settings, both UCTs and CCTs relax the budget constraint and allow households to enroll more of the children they would traditionally prioritize for human capital investments. But the conditions attached to CCTs play a critical role in improving the outcomes of children for whom parents are less likely to invest.</SPAN></p>
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<p><B><SPAN style="FONT-SIZE: 11pt">Implications for policy</SPAN></B></p>
<p><B>&nbsp;</B></p>
<p><SPAN style="FONT-SIZE: 11pt">The policy implications of our results are clear: the choice between CCTs and UCTs should be influenced by the objectives of the education policy. </SPAN></p>
<p><SPAN style="FONT-SIZE: 11pt">·<SPAN style="FONT: 7pt 'Times New Roman'">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN></SPAN><SPAN style="FONT-SIZE: 11pt">If the objective is to increase overall enrollment, UCTs might have comparable effects to CCTs. </SPAN></p>
<p>&nbsp;</p>
<p><SPAN style="FONT-SIZE: 11pt">·<SPAN style="FONT: 7pt 'Times New Roman'">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </SPAN></SPAN><SPAN style="FONT-SIZE: 11pt">If the policy objective also includes an emphasis on improving the enrollment and educational outcomes of categories of children who are less likely to be part of the education system, then CCTs are likely to have larger impacts and be more cost-effective. That conclusion is especially relevant in the context of Millennium Development Goal 3 which focuses on reducing the gender gap in education.</SPAN></p>
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<p><SPAN style="FONT-SIZE: 11pt">From a policy-making perspective, our study also addresses the feasibility of conditional cash transfer schemes in the sub-Saharan African context. Since CCT programs rely on a certain level of administrative capacity (the ability to target households, plan meetings to notify households of their obligations and rights, monitor household compliance and conditionality, and transfer funds to families), there is a debate on whether these programs, which have been successful in Latin America, can be successfully implemented by African central or local governments. </SPAN></p>
<p>&nbsp;</p>
<p><SPAN style="FONT-SIZE: 11pt">The cash transfer program we study relied on existing government structures and was implemented in an environment where there is no systematic population registration and where formal banking is almost non-existent. The logistics of the cash transfers did not involve advanced technologies. The government distributed the cash transfers during a meeting convened every quarter in a central location in each village. In the CCT villages, school enrollment and attendance were verified with a signature by the school director in a program booklet, with a random audit of the school register for a subset of children. Even though our study was a two-year pilot limited to one province and its scalability remains to be investigated, it nevertheless indicates that CCTs can be implemented and be effective in an environment with limited administrative capacity.</SPAN></p>
<p>&nbsp;</p>
<p><SPAN style="FONT-SIZE: 11pt"><A href="http://faculty.las.illinois.edu/akresh/"><FONT color=#0000ff>Richard Akresh</FONT></A> <SPAN style="COLOR: black">is an Assistant Professor of Economics at the University of Illinois at Urbana-Champaign.</SPAN></SPAN></p>
<p><SPAN style="FONT-SIZE: 11pt"><A href="http://go.worldbank.org/0TJZWJJCM0"><FONT color=#0000ff>Damien de Walque</FONT></A><SPAN style="COLOR: black"> is a Senior Economist in the Development Research Group at the World Bank</SPAN></SPAN></p>
<p><SPAN style="FONT-SIZE: 11pt"><A href="http://www.hkazianga.org/"><FONT color=#0000ff>Harounan Kazianga</FONT></A> is an </SPAN><SPAN style="FONT-SIZE: 11pt">Assistant Professor of Economics, Department of Economics, William Spears School of Business, Oklahoma State University</SPAN></p>
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<p><A title="" href="http://blogs.worldbank.org/impactevaluations/node/add/blog#_ftnref1" name=_ftn1><SPAN><SPAN><SPAN><SPAN style="FONT-SIZE: 10pt"><FONT color=#0000ff>[1]</FONT></SPAN></SPAN></SPAN></SPAN></A><FONT size=2> We are aware of one other cash transfer project in Morocco, the Tayssir program, with a design similar to ours, which examines the impact of conditionality on educational outcomes.</FONT></p></p></p>Thu, 31 Jan 2013 09:12:23 -0500Damien de WalqueRewarding safe sexhttps://blogs.worldbank.org/africacan/rewarding-safe-sex
<P>Prevention strategies have had limited impact on the trajectory of the HIV/AIDS epidemic. New, innovative approaches to behavioral change are needed to stem the epidemic.</P>
<P>In a joint effort with many colleagues, and in collaboration with the Ifakara Health Institute in Tanzania and, the University of California at Berkeley, we launched a study with the acronym RESPECT (“Rewarding STI Prevention and Control in Tanzania”).</P>
<P>We started with an observation:&nbsp; Conditional cash transfers (CCTs) have been used successfully to promote activities that are beneficial to the participants such as school attendance&nbsp; and health check-ups for children.&nbsp; The Tanzanian experiment asks whether CCTs can be used to prevent people from engaging in activities that are harmful to themselves and others, such as unsafe sex. This is a controversial idea. <!--break-->Shouldn’t people be trusted to do what is good for them, without being promised financial incentives? Do African women have enough control over their sexual life so that they could respond to those incentives?&nbsp;</P>
<P><A href="http://bmjopen.bmj.com/content/2/1/e000747.full.pdf+html">The results from the study have recently been published</A><SUP>1</SUP>.&nbsp; The findings suggest that financial incentives – participants receive a cash payment if they remained negative for a set of curable sexually transmitted infections (STIs) – could be an effective prevention tool for STIs and possibly HIV. In rural Tanzania, among study participants who were randomly selected to be eligible for a $20 payment every 4 months if they tested negative for a set of curable STIs, researchers saw a 27% reduction in the incidence of those STIs (adjusted results) after one year.</P>
<P>The RESPECT study is a randomized controlled trial testing the hypothesis that a system of rapid feedback and positive reinforcement using cash as the primary incentive can be used to reduce risky sexual activity among young people, male and female, who are at high risk of HIV infection.&nbsp; The study enrolled 2,399 participants in 10 villages in the Kilombero/Ulanga district of south-west Tanzania, located 100 kilometers south of the major highway linking Dar Es Salaam, with Zambia and Malawi. It had three separate arms – a control arm and two treatment arms (low-value treatment and high-value treatment).&nbsp; Study participants were randomly allocated across the three study arms. All participants have been monitored on a regular basis (every 4 months over a 12 month period) for the presence of common sexually-transmitted infections (STIs) that are transmitted through unprotected sexual contact and therefore serve as a proxy for risky sexual behavior and vulnerability to HIV infection.&nbsp; A small payment was provided to all participants (regardless of arm assignment) to minimize attrition from the study.&nbsp; Anyone testing positive for an STI (again, regardless of arm) received free treatment and counseling. Individual pre-test and post-test counseling was provided to study enrollees at each testing interval, and monthly group counseling sessions were also made available to all study participants in all villages.</P>
<P>The primary outcome for evaluating impact is a set of sexually-transmitted infections (STIs) that are prevalent within this population and have been incontrovertibly linked to risky sexual activity.&nbsp; These are: chlamydia, gonorrhea, trichomonas, mycoplasma genitalium, and syphilis.&nbsp; Each of these STIs is curable.&nbsp; This is a critical point, since enrollees who test positive for an STI could continue to participate in the study after they had been treated and cured of the infection.&nbsp; Thus, learning was encouraged through positive reinforcement, and mistakes could be corrected and overcome.&nbsp; For both ethical and practical reasons, the cash transfers were not tied to HIV status, and HIV acquisition did not result in being dropped from any arm of the study.</P>
<P>The treatment arm received conditional cash transfers (CCTs) that depended on negative results of periodic screenings for incident sexually transmitted. The treatment arm was further divided into two sub-groups – one receiving a “high value” CCT payment of up to $60 over the course of the study ($20 payments every four months) and the other receiving a lower value payment of up to $30 ($10 payments every four months). These amounts represent a significant proportion of household income in a country where GDP per capita was $440 in 2008, and particularly among our study participants who had mean individual annual earnings of approximately $250. A comparison between the impact of the intervention in the high-value cash transfer arm to that in the low-value cash transfer arm allows us to better understand at which threshold CCT can be effective as an HIV/STI prevention tool. While the results showed a significant reduction in STI incidence in the group that was eligible for the $20 quarterly payments, no such reduction was found for the group receiving the $10 quarterly payments. Further, the impact of the CCTs did not differ between males and females.</P>
<P>While the results are important in showing that financial incentives can be a useful tool in preventing HIV/STI transmission, we are still at an early stage. This approach would need to be replicated elsewhere and implemented on a larger scale before it could be concluded that such conditional cash transfer programs (for which administrative and laboratory capacity requirements are significant) offer an efficient, scalable and sustainable HIV prevention strategy.&nbsp; The extraordinarily high social and economic cost of the current HIV/AIDS crisis suggests that prevention can be far cheaper than treatment.&nbsp; We must continue to search for innovative and effective prevention approaches.</P>
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<P><SPAN style="FONT-SIZE: smaller"><SUP>1</SUP>. de Walque D, Dow WH, Nathan R, et al. Incentivising safe sex: a randomised trial of conditional cash transfers for HIV and sexually transmitted infection prevention in rural Tanzania. BMJ Open 2012;2:e000747. doi:10.1136/bmjopen-2011-000747</SPAN></P>Mon, 05 Mar 2012 10:48:06 -0500Damien de Walque